The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT AGNES MEDICAL CENTER 1303 E HERNDON AVE FRESNO, CA 93710 Oct. 3, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interview, clinical record and administrative document review, the hospital failed to comply with the provisions of CFR 489.24 when:

Three of thirty patients (Patients 1, 13 and 18) were diagnosed with psychiatric emergency conditions and an assessment was not performed and stabilizing measures not identified by the clinical social worker for two of the patients (Patients 1 and 18); and two of the patients (Patient 1 and 13) were transferred to a psychiatric crisis stabilization center (PCSC) and returned back to the emergency department (ED) in the same condition (5150 hold and suicidal - [Welfare and Institution Code 5150 hold authorizes involuntary confinement for danger to self, danger to others or gravely disabled]) in less than 24 hours.

These failures to provide stabilizing measures within the capabilities of the hospital resulted in possible preventable involuntary re-hospitalization and the potential of patient harm and injury during possible unnecessary transfer of patients. (refer to A2407)
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on staff interview, clinical record and administrative document review, the hospital failed to maintain a central log that tracks the care of patients through the emergency department when the central log did not accurately document the discharge diagnosis or the discharge disposition in 796 of 1531 patients seen for identified days (9/20/14, 9/22/14, 3/1/14, 11/25/13, 11/24/13, 10/4/13, and 10/3/13).

This failure resulted in not identifying predictable patterns of patient flow and missed opportunities for process improvement.

Findings:

Record review of the Emergency Department (ED) central logs showed each patient was to have the following information tracked on the log: patient name, Financial Information Number (FIN - specific to the patient and the hospital visit), the Medical Record Number (MRN - specific to the patient), age, check in date and time, check out date and time, reason for visit, doctor exam, acuity, how the patient arrived at the hospital, Primary Care Physician (PCP), Length of Stay (LOS), Room/Bed, Discharge Diagnosis (DC Diag), Emergency Department Disposition (ED Disp), and Final Disposition (Final Disp).

Record review of the following ED logs for dates 9/20/14, 9/22/14, 3/1/14, 11/25/13, 11/24/13, 10/4/13, and 10/3/13 showed the ED/Final disposition and/or discharge diagnosis was missing for 796 of 1531 patients seen.

The dates, missing information, and number of patients involved were as follows:

9/22/14 65 missing Discharge Diagnosis, 27 missing both ED/Final Disposition (Disp); total number of patients seen this day: 267
9/20/14 62 missing Discharge Diagnosis, 19 missing both ED/Final Disp; total number of patients seen this day: 226
3/1/14 136 missing Discharge Diagnosis, 27 missing both ED/Final Disp; total number of patients seen this day: 215
11/25/13 103 missing Discharge Diagnosis, 5 missing both ED/Final Disp; total number of patients seen this day: 200
11/24/13 111 missing Discharge Diagnosis, 2 missing both ED/Final Disp; total number of patients seen this day: 204
10/4/13 92 missing Discharge Diagnosis, 18 missing both ED/Final Disp; total number of patients seen this day: 213
10/3/13 117 missing Discharge Diagnosis, 12 missing both ED/Final Disp; total number of patients seen this day: 206

Of the 1531 patient ED log entries reviewed, 796 were missing either the Discharge Diagnosis, both the ED and Final Disposition, or all three.

On 10/3/14 at 10 a.m., during a concurrent interview, the ED Director and ED Manager stated that neither one of them reviewed the ED central log on a regular basis. The ED Manager and ED Director stated prior to the start of this survey (9/30/14), they were not aware of the missing information and inaccuracy of the ED central log. The ED Manager and ED Director stated that they did not use the ED central log to trend data and identify patterns of patient services.

The facility policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA), Transfer Protocol" review dated October 2011, indicated "....DOCUMENTATION:...3. A central log for all individuals who come to the ED will be maintained for a minimum of five years. This will include the following: Patient name, age, date/time of arrival, account number, mode of arrival, chief complaint, acuity -Emergency Severity Index, physician name, disposition, and disposition date/time...."

No policy and procedure was provided that addressed the need for accuracy and review of the ED central log.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, clinical record and administrative document review, the hospital failed to ensure stabilizing measures were provided within the capabilities of the hospital when:

Three of thirty patients (Patients 1, 13 and 18) were diagnosed with psychiatric emergency conditions and an assessment was not performed and stabilizing measures not identified by the clinical social worker for two of the patients (Patients 1 and 18); and two of the patients (Patient 1 and 13) were transferred to a psychiatric crisis stabilization center (PCSC) and returned back to the emergency department (ED) in the same condition (5150 hold and suicidal - [Welfare and Institution Code 5150 hold authorizes involuntary confinement for danger to self, danger to others or gravely disabled]) in less than 24 hours.

These failures to provide stabilizing measures within the capabilities of the hospital resulted in possible preventable involuntary re-hospitalization and the potential of patient harm and injury during possible unnecessary transfer of patients.

Findings:

The clinical record indicated Patient (Pt) 1 was admitted on [DATE] at 3:06 a.m. by ambulance on a 5150 hold (Welfare and Institution Code authorizing involuntary confinement for danger to self, danger to others or gravely disabled) for suicidal attempt. Pt 1's reason for admission was "5150, danger to self, ETOH (alcohol) use, hang himself attempt". Pt 1 was triaged (clinical process to prioritize presenting reason to the emergency department [ED]) on 9/20/14 at 3:09 a.m. by Registered Nurse (RN) 1 with a triage class (a process of determining the priority of patients' treatments based on the severity of their condition) of "2 Urgent". Pt 1's medical screen exam (MSE - the physical exam performed by the physician to determine whether or not there exists an emergency medical condition) was started on 9/20/14 at 3:55 a.m. by medical doctor (MD) 1. The doctors orders indicated a "social work consult" order on 9/20/14 at 9:11 a.m. The Clinical Social Worker (CSW) 1 progress note on 9/20/14 at 10:09 p.m. indicated, "...Per chart review, [Pt 1] placed on a 5150 hold for 72 hour detention and psychiatric evaluation as pt had a suicide attempt at home...Pt has been medically clear for discharge...d/t [due to] gravity of pts actions...pt remains on 5150 hold for transfer to a psychiatric facility for further evaluation". The CSW 1 progress note did not indicate an assessment of Patient 1 had occurred. The CSW 1 progress note did not address history of suicidal attempts, possible triggers leading up to the suicidal attempt or stabilizing measures identified by the social worker. The "Emergency Department Discharge Summary" indicated Pt 1 was transferred to a psychiatric crisis stabilization center (PCSC) on 9/21/14 at 7:05 p.m. The "Physicians Transfer Certification" indicated the "reason for transfer" was "higher level of [psychiatric] care needed". The "Patient Transfer Flowsheet and Checklist" indicated Pt 1 was "stabilized" for transfer and physician to physician communication was documented. The clinical record indicated Patient 1 was in the ED for 40 (forty) hours without a mental health assessment by the social worker prior to transfer to the PCSC.

The clinical record indicated Pt 1 was re-admitted on [DATE] at 6:37 p.m. by ambulance on a 5150 hold/suicidal and transferred from the PCSC. Pt 1's reason for admission was documented as, "return/Timed Out from [PCSC]". Pt 1 was triaged on 9/22/14 at 6:41 p.m. by RN 2 with a triage class of "2 Urgent". Pt 1's MSE was started on 9/22/14 at 9:41 p.m. by MD 2. Patient 1 was medically cleared on 9/22/14 at 10:06 p.m. and a social work consult was obtained. The progress note by CSW 2 on 9/23/14 at 3:25 a.m. indicated, "...Interviewed patient [Patient 1] alone at bedside...patient had been evaluated by nursing staff and a psychiatrist at [the PCSC] and was not considered safe enough to have the original WIC [Welfare and Institutions Code] 5150 rescinded and be released back to the community...patient is considered a continued risk of potential self-harm and is placed on a subsequent WIC 5150 this date at 2:36 a.m...Advised the patient I would have Social Services staff look into the matter further, including possibly having a psychiatrist evaluate him here at [the hospital]. Elected not to send out packets [request for inpatient psychiatric bed] at this point...pending further follow up..." The progress note by CSW 3 on 9/23/14 at 1:04 p.m. indicated Pt 1 was accepted at an In-patient Psychiatric Hospital (IPH). The "Emergency Department Discharge Summary" form indicated Pt 1 transferred to an IPH on 9/23/14 at 1:44 p.m.. The "Physicians Transfer Certification" indicated the reason for transfer was "higher level of care" and the benefits were "psychiatric evaluation and tx [treatment]". The "Patient Transfer Flowsheet and Checklist" indicated Pt 1 was "stabilized" for transfer. The clinical record indicated Patient 1 was in the ED for an additional 19 hours prior to the transfer to an IPH. The clinical record for Patient 1 indicated the continuous total time spent in the ED and PCSC from the first admission on 9/20/14 through the transfer to the IPH on 9/23/14 was approximately 82 hours.

The clinical record indicated Pt 18 was admitted via ambulance on a 5150
suicidal attempt hold initiated by a local police department on 4/02/14 at
1:40 a.m. Pt 18's reason for admission was "5150, ETOH [alcohol]". Pt
18 was triaged on 4/2/14 at 1:41 a.m. by RN 3 with a triage class of "2
Emergent". Pt 18's MSE was started on 4/2/14 at 1:55 a.m. by MD 3. Pt
18 was medically cleared by MD 3 on 4/2/14 at 5:53 a.m. The progress
Note by CSW 3 on 4/2/14 at at 9:51 a.m. indicated, "Pt BIBA [brought in
by ambulance] on WIC 5150 DTS [due to suicide] by [local police
department] at 4/2/14 1 a.m. Packet was faxed by staff (unit secretary) and
Pt was accepted at [PCSC] by staff RN [registered nurse]. Transfer
paperwork completed and transport arranged by RN." The CSW progress
note did not indicate an assessment of Patient 1 had occurred. The CSW
progress note did not address history of suicidal attempts, possible
triggers leading up to the suicidal attempt or stabilizing measures identified
by the social worker. The "Patient Transfer Flowsheet and Checklist"
dated 4/2/14 indicated Pt 18 was "stabilized" for transfer, physician to
physician communication had taken place and accepted at the PCSC on
4/2/14 at 9 a.m. Review of the ED logs and the hospital electronic health
record indicated Patient 18 did not have return visits to the ED and was not
admitted to the hospital.

The clinical record indicated Pt 13 was admitted via ambulance on 4/25/14 at 11:24 a.m.. Pt 13's reason for admission was "5150, danger to self". Pt 13 was triaged on 4/25/14 at 11:26 a.m. by RN 6 with a triage class of "3 Urgent". Pt 13's MSE was started on 4/25/14 at 11:47 a.m. by MD 5. Pt 13 was medically cleared on 4/25/14 at 1:33 p.m. The progress note by CSW 4 on 4/25/14 at 6:59 p.m. indicated, Pt 13 was "... alert and oriented X 3 (meaning oriented to person, place and time)...mood calm, guarded and affect..flat ...[Pt 13] now agitated, masturbating and yelling out when told to stop ...security is present ...pt to remain on 5150 hold and will fax out to the psych facilities". The "Discharge/Transfer" form indicated Pt 13 was transferred to the PCSC on 4/27/14 at 2:21 a.m. The "Patient Transfer Flowsheet and Checklist" indicated Pt 13 was "stabilized" for transfer and his care was accepted by MD 6 at the PCSC; the reason for Pt 13's transfer to the PCSC was documented as "Higher Level of [psychiatric] Specialty Care Needed".

The clinical record indicated Pt 13 was readmitted to the hospital ED via
ambulance from PCSC on 4/28/14 at 2:20 a.m. The reason for re-
admission was documented as, "Return from [PCSC], Hold Expires 11:08
today". Pt 13 was triaged on 4/28/14 at 2:29 a.m. by RN 7 with a triage
class of "2 Emergent". Pt 13's MSE was started on 4/28/14 at 4:46 a.m. by
MD 7. Pt 13 was medically cleared on 4/28/14 at 5 a.m. The progress note
by CSW 3 on 4/28/14 at 11:30 a.m. indicated, "Met with pt [Patient 13]
...has been cooperative and calm since his return from [PCSC] ...spoke
to..father ...advised [father] he would need to pick [Pt 13] up ...will send pt
home by taxi if his father does not come to pick him up'. The
"Discharge/Transfer" form indicated Pt 13 was discharged home on
4/28/14 at 2:08 p.m. in "stable" condition with mode of departure listed as
"ambulate". Pt 13 signed the "Client Discharge Plan" that indicated
"Follow Up Appointment at [local clinic] or Primary doctor". Pt 13's
discharge diagnosis was listed as "SI (suicidal ideation), Psychosis".

On 10/1/14 at 1 p.m., during an interview, the ED Medical Director (MD 8)stated he was familiar with the care of Patient 1 and confirmed all patients admitted into the ED on 5150 hold with suicidal ideation/attempt would be considered an emergency medical condition. MD 8 stated patients that fit in this category would always be worked up medically in order to determine whether or not there was a medical reason for the psychiatric emergency condition. MD 8 stated all psychiatric emergency condition patients would receive a social work consult once the patient was cleared medically. MD 8 stated the expectation was for a social work consult to result in an assessment and evaluation that would assist the ED physician in the decisions needed to provide stabilizing measures. When asked whether there was a protocol to assist and direct hospital staff in the expectation for social services and the determination of stabilizing measures for psychiatric emergency patients he said "no". MD 8 acknowledged Patient 1 did not receive a face to face assessment from the social worker on the 9/20/14 visit. When asked whether or not there was a monitoring system in place to track and determine whether social work consults resulted in an assessment and evaluation he stated "no". When the topic of transferring patients to the PCSC was brought up, MD 8 stated the facility was county run and he considered the facility a 'community plan' and was an important method to deal with the influx of patients placed on 5150 hold and suicidal. MD 8 stated the PCSC was equipped in handling this type of patient and had on staff psychiatrists, psychologists, RNs and psychiatric technicians as well as social workers. MD 8 acknowledged that occasionally patients returned back to the hospital ED because the time limit at the PCSC was 23 hours and 59 minutes. MD 8 stated he acknowledged the PCSC was not considered an inpatient psychiatric hospital. MD 8 stated there was no ED protocol that guided and directed the hospital staff to determine whether or not to transfer to an in-patient psychiatric hospital versus the PCSC. When asked to comment and contrast the difference of transfers for 'higher level of care' to the PCSC and to Inpatient Psychiatric Hospitals MD 8 did not offer a comment. When asked whether the hospital ED accepted transferred back patients from in-patient psychiatric hospitals, MD 8 stated "no". When asked whether any hospital committee (such as Quality Improvement, Safety Committee or departmental meeting) occurred with minutes dedicated to discussing the risks and benefits of transferring to the PCSC MD 8 stated "no". When asked whether any ED committee meeting discussed EMTALA and the risks and benefits of transferring to the PCSC MD 8 stated "no".

On 10/1/14 at 2 p.m., during a concurrent interview, the ED Nursing Director (EDD) and the ED Manager (EDM) stated they were familiar with the care of Patient 1 and confirmed all 5150 hold and suicidal patients admitted to the ED were considered emergencies and routinely triaged at an ESI of 2 (urgent). EDD and EDM stated there was no protocol or ED policy and procedure that guided and directed ED Staff and providers on the decision tree, services and stabilizing measures for psychiatric emergency patients. The EDD and EDM stated the expectation was for all 5150 hold/suicidal patients to receive a social work consult. The EDD and EDM stated there was no monitoring tool in place that tracked whether or not assessments and evaluations were done by social workers. The EDD and EDM stated that the RN assigned to the patient often placed a nursing order for a social work consult for psychiatric emergency patients. The EDD and EDM stated the expectation was that the social worker would pass on information about the social work consult to the assigned RN or ED physician. The EDD and EDM stated there was no monitoring tool to track whether or not that was done. The EDD and EDM stated they were aware the social worker called to consult for Patient 1 on 9/20/14 did not conduct an assessment and evaluation and did not identify stabilizing measures. The EDD and EDM acknowledged that assessments, evaluations and identification of stabilizing measures for 5150/suicidal patients occasionally were not done when the ED was busy with these types of patients. On the topic of transferring to the PCSC, the EDD and EDM stated transfers to the PCSC were done "all the time" and was needed as a "release valve" to handle the influx of ED patients brought in under 5150 hold and suicidal. The EDD and EDM stated the PCSC was well staffed with professionals (psychiatrists, psychologists, mental health workers, registered nurses and psychiatric technicians) that could handle psychiatric emergencies. When asked if all psychiatric 5150 hold/suicidal patients that needed 'higher level of care' were transferred to the PCSC, the EDD and EDM stated 'no'. The EDD and EDM stated there was no protocol that guided and directed the hospital staff to determine whether or not to transfer to an in-patient psychiatric hospital versus the PCSC. The EDD and EDM acknowledged the PCSC was not an in-patient hospital. The EDD and EDM acknowledged that occasionally transferred patients to the PCSC were transferred/readmitted back to the ED because of 'timing out' and acknowledged the PCSC did not hold patients longer than 23 hours and 59 minutes. When asked whether the hospital ED accepted transferred back patients from in-patient psychiatric hospitals the EDD and EDM stated "no". The EDD and EDM stated the practice of transferring patients to the PCSC had been going on since about May 2012. When asked whether there was a formal hospital committee or any meeting minutes that documented discussion and the decision to transfer patients to the PCSC, the EDD and EDM stated they did not know.

On 10/2/14 at 11 a.m., during an interview, CSW 1 stated she was called to consult on Patient 1 for his visit of 9/20/14. CSW 1 stated she did not assess Patient 1, did not introduce herself to Patient 1, and only completed a record review of Patient 1's ED visit. CSW 1 offered the following rationale for the decision not to conduct an assessment and evaluation of Patient 1: "... it was the week-end, and there were several patients in the ED that needed to be seen..." and that she had been directed to prioritize patients whose 5150 holds could be lifted before patients that had recently been admitted to the ED with 5150 hold and suicidal. CSW 1 stated the priority was to get patients released from their 5150 hold since recently admitted patients would probably be transferred to a psychiatric facility. When asked whether the social work consult was required in a new psychiatric 5150 hold suicidal patient she stated "yes". CSW 1 stated that ideally all patients diagnosed with a psychiatric emergency needed a social work consult and should receive a face to face assessment and evaluation and identification of stabilizing measures.

On 10/2/14 at 2 p.m., during a concurrent interview, the Director of Case Management and Social Services (DCMSS) and the Manager of Social Services (SWM) stated they were familiar with the care of Patient 1. The DCMSS and the SWM confirmed all patients admitted into the ED with a psychiatric emergency and that were medically cleared would receive a social work consult. The DCMSS and the SWM stated the social work consult provided a crucial role in identifying stabilizing measures to assist the ED physician treat psychiatric emergencies. The DCMSS and the SWM stated the expectation was that each social work consult for patients with a psychiatric emergency would result in a face to face assessment and evaluation. The DCMSS and the SWM were familiar with the care of Patient 1 and acknowledged the ED visit for 9/20/14 did not result in a social worker assessing and evaluating the patient. The DCMSS and SWM acknowledged that occasionally psychiatric emergency patients brought in by 5150 hold/suicidal did not result in a social work assessment and evaluation. The DCMSS and SWM stated there was no social services monitoring tool to track when assessments were not done by social workers for psychiatric emergencies in the ED. The DCMSS and SWM stated the process to provide transfer for psychiatric emergencies, such as suicidal patients on 5150 hold, did not differentiate between in patient hospitals (IPH) and the PCSC. The DCMSS and SWM stated they were aware of the 23 hour and 59 minute time limit for patients transferred to the PCSC. The DCMSS and SWM were aware the PCSC was not an inpatient psychiatric hospital.

On 10/2/14 at 3:30 p.m., during an interview, the Director of Quality and Risk Management (DQRM) stated she was familiar with the care of Patient 1 and the transfer of patients with 5150 hold/suicidal to the PCSC for 'higher level of care'. The DQRM stated the use of PCSC as a facility to transfer patients had been going on since May 2012. The DQRM stated the rationale for the decision was based on "community plan" for dealing with the influx of patients on 5150 hold and suicidal. The DQRM stated the PCSC was endorsed by the local hospital council and the board of supervisors for the county. The DQRM stated the PCSC filled the role as a "release valve" in handling the many patients seen with 5150 hold and suicidal. The DQRM was aware the limit for the stay of patients at the PCSC was 23 hours and 59 minutes. The DQRM stated, as far as she was aware, no hospital committee had discussed the benefits and risks of transferring patients to the PCSC. The DQRM stated there had been no governing body committee meeting or minutes devoted to the decision to utilize the PCSC as a receiving facility in the transfer of patients from the ED.

On 10/3/14 at 11 a.m., during an interview, the program director for the PCSC (EPD) discussed the role of the PCSC in the care of patients with psychiatric disorders. The EPD stated the PCSC specialized in crisis stabilization of mental health patients and was equipped to handle patients on 5150 hold and suicidal. The EPD stated the facility was approved to provide this type of service by the county. The EPD stated that the facility always had a psychiatrist or psychologist on call and that the facility was also staffed with registered nurses, social workers, mental health specialists and psychiatric technicians. The EPD stated the facility was not an in-patient psychiatric facility and the time limit for each patient was 23 hours and 59 minutes. The EPD stated the PCSC often accepted patients transferred from hospital EDs, and if the patient was not stabilized within the 23 hour 59 minute time limitation, the patients were transferred back to the sending hospital. The EPD stated many times transferred patients on 5150 hold and suicidal would be successfully treated and discharged from the facility.

The facility policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Transfer Protocol" dated October 2011, indicated, "...OUTCOME: All individuals who come to the hospital for examination and treatment of a potential emergency medical condition will receive a screening examination and stabilizing treatment... DEFINITIONS: 4. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including pain), psychiatric disturbances and/or symptoms of substance abuse such that the absence of immediate medical attention could reasonable be expected to result in placing the health of an individual...in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part....6. Stabilized/Obstetrical: If transferring, the physician responsible for the individual must determine whether the individual's medical condition is stabilized (i.e., that within reasonable medical probability, the transfer or delay caused by the transfer will not result in a material deterioration in, or jeopardy to, the medical condition or expected chances for recovery of the individual;...POLICY AND PROCEDURE: 1. Examination and Treatment:...E. After determining that an emergency condition exists, further examination and treatment will be provided within the capabilities of the staff and facilities available at the hospital, until the individual's condition is stabilized or an appropriate transfer is made...3. There may be other times when there is no on-call availability in a certain specialty. In those limited instances, it is the policy of [the hospital] that the ED physician will assess alternate treatment options for the patient and appropriately transfer the patient to another facility capable of meeting the patient's clinical needs, including specialty care...2. Transfer A. A patient in stable condition may be transferred from the hospital when: 1) A physician or other qualified medical person makes a determination of the medical benefits reasonable expected from treatment at another facility outweigh the risk of transfer...DOCUMENTATION:...3. A central log for all individuals who come to the ED will be maintained for a minimum of five years. This will include the following: Patient name, age, date/time of arrival, account number, mode of arrival, chief complaint, acuity - Emergency Severity Index, a physician name, disposition, and disposition date/time.

The facility administrative document titled "Clinical Social Services Patient Care Standard" dated "reviewed: May 2014" indicated "Subject: Suicide (Self Harm) Homicide Risk Screening and Assessment Policy...POLICY: 1. Adult Population: All patients over the age of eighteen will be screened for suicide risk as a part of the initial nursing assessment. 2. Pediatric Population: Any child under the age of eighteen who presents with a primary emotional or behavioral (mental) disorder shall be screened for suicide risk (as appropriate for the child ' s developmental age). PROCEDURE: 1. Should the patient answer affirmatively (yes) to any questions on the Suicide/Homicide Risk Screening that may indicate a current imminent potential risk for suicide/homicide: A. An immediate, verbal referral shall be made to the Clinical Social Services staff covering the ...emergency department...2. Should the positive screen indicate current potential ' risk ' for suicide/homicide: Emergency Department...The Social Services staff member will consult with the ED staff (RN/MD) regarding patient ' s medical status and upon medical clearance the Social Services staff member will assess the patient from a psychosocial perspective to include environmental/psychological stressors, as well as current suicide risk (risk/no risk). Upon determination that the patient meets criteria as a ' danger to self/others, or gravely disabled, ' the licensed Social Services staff shall complete the WIC 5150 paperwork, alerting the RN/MD and Security of the hold. The Social Worker will alert the patient to the specifics inherent within the psychiatric hold, as well as advising the patient of: the plan to seek inpatient psychiatric placement...The Social Worker shall begin process of seeking to secure an inpatient psychiatric bed. The search shall include local facilities as priority, though state-wide expanded search may be necessary...Involuntary Holds For Psychiatric Evaluation - 5150, PROCEDURE: The treating physician and/or [hospital] staff may request that the Social Services Department evaluate a patient. When the patient has been medically cleared...the designated Social Services staff will evaluate the patient (if not already on WI 5150 hold). If the patient meets criteria for a psychiatric hold, the Social Worker shall complete the WIC 5150 form and then begin to seek placement in an inpatient psychiatric facility. If the patient had been placed on a WIC 1799 hold prior to the institution of the WIC 5150, the Social Services personnel shall credit " time served " (from 1799 hold) when completing the 5150 hold.. The process is as follows: A. The Social Worker shall be responsible for locating an accepting psychiatric facility and arranging the transfer. This will include contacting all local facilities :...[including PCSC]... for bed availability. If there are no inpatient psychiatric beds available locally, it is the responsibility of the Social Worker to search throughout California for an available bed... "

The facility administrative document titled "Clinical Social Services Patient Care Standard" dated "reviewed: December 2013" , indicated "Subject: Psychosocial Assessment...POLICY: A psychosocial assessment instrument within Power Chart is used as a means of conceptualizing the patient's current situation in an effort to determine needs. PROCEDURE: 1. Upon receipt of a referral for Social Services, the Social Worker shall review note sin Power Chart; both current entries, as well as, prior visit documentation (if appropriate). 1. The Social Services assessment shall focus upon the follow areas (encompassed within Power Chart ' s Social Work Assessment framework): a. Contact Person/Support Person b. Adjustment to illness c. Emotional/Psychological Status...e. Family Situation f. Financial Situation...i. Orientation/Interaction...p. Discharge Evaluation...u. Social Work Note. 3. In completing Social Work documentation in Power Chart, it is not necessary to address each and every element within the template. However, the elements followed by an asterisk must be addressed within the narrative 'Social Work Note' section' ...4. The Social Worker shall consult with the appropriate disciplines (nursing, care coordination, physicians) as needed regarding the patient's plan of care. "

The facility ' s administrative documented, titled "Position Description: Licensed Social Worker dated 8/23/10, indicated "...ROLE SPECIFIC ACCOUNTABILITIES, 6. Responsible for assessing for, and writing of WIC 5150 holds when appropriate, followed by facilitation of patient transfers to inpatient psychiatric facilities when indicated. 7. Comprehensively analyze patient and family situations that will require advance advocacy and knowledge of community resources. Recognize problems, systematically gather data, identify/understand underlying issues, synthesize complex issues, seek input from others and make difficult decisions to formulate appropriate treatment plans.